7. PROJECT SUMMARY Atrial fibrillation (AF) is a common, highly morbid, and chronic condition. Long-term adherence to anticoagulation is a necessity for stroke prevention in AF but demanding for patients to maintain. For rural patients with chronic AF, anticoagulation adherence may be challenged by geographic isolation, decreased clinician access, social and economic vulnerability, and limited health literacy. We have developed a smartphone-based mobile health (mHealth) intervention that uses self-management to improve adherence to anticoagulation and quality of life in AF. Our intervention consists in an embodied conversational agent (ECA), a computer character that simulates face-to-face conversation using voice, hand gesture, and gaze cues to provide education, monitoring and problem-solving. We have used the ECA in multiple health contexts for self- management and demonstrated its success for improving adherence in individuals with limited computer and health literacy. We have piloted our limited ECA for AF that integrated the AliveCor Kardia smartphone heart rate and rhythm monitor. We now aim to augment our ECA content, combined with the Kardia and clinical alerts administered through the electronic health record (EHR). We will develop novel ECA content focused on strategies for anticoagulation adherence; common AF symptoms and their correlation with Kardia findings; communication strategies; quality of life; and chronic disease self-management. We will conduct our ECA/Kardia and EHR alert self-management intervention in patients with chronic AF residing in rural Pennsylvania, a highly vulnerable patient demographic. We will leverage the University of Pittsburgh Medical Center's common EHR and rural clinics to enroll 360 participants from 13 rural Pennsylvania counties and randomize them 2:1 to receive the ECA/Kardia with EHR alerts (n=240) or control (n=120) for 4 months and follow them for 12 months. Our aims are: (1) To evaluate the effect of the ECA/Kardia and EHR alert intervention on anticoagulant adherence. We will quantify adherence using the medication possession ratio and pharmacy contact at 12 months, and complementary measures of self-reported non-adherence and the Morisky 8-item Medication Adherence Score at baseline, 4, and 12 months. (2) To examine the effect of the intervention on symptoms and quality of life. We will evaluate quality of life with the Patient-Reported Outcomes Measurement Information System-29 Profile and the AF-specific Atrial Fibrillation Effect on QualiTy of life (AFEQT) measure at baseline, 4, and 12 months. (3) To determine the effect of the intervention on health care utilization at 12 months using EHR and health claims data. We will engage an 8-member patient advisory committee of rural individuals with chronic AF to guide the intervention's cultural acceptability, our recruitment, and presentation of results. Expected Results: In this project we will evaluate a scalable patient- centered intervention to improve anticoagulation adherence, improve quality of life, and reduce health care utilization in vulnerable, rural individuals with chronic AF.